Your Lung Operation Booklet

AMERICAN COLLEGE OF SURGEONS DIVISION OF EDUCATION SURGICAL PATIENT EDUCATION Table of Contents

Welcome...... 1 Your Lungs...... 2 Lung Cancer ...... 3 SURGICAL Understanding Your Operation...... 4 PATIENT Preoperative Tests ...... 5 EDUCATION Home Preparation ...... 8 The Day of Your Operation...... 13 After Your Operation...... 14 Your Recovery and Discharge...... 17 When to Call Your Doctor...... 19

Welcome You and your family are important members of the surgical team. The American College of Surgeons (ACS) “Your Lung Operation: Education for a Better Recovery” program will help you prepare for your operation and recovery. You and your family will know what to expect. You will learn how to work with your surgical team to ensure that you have the best surgical outcomes.

COMPLETE THE “YOUR LUNG OPERATION” EDUCATION PROGRAM: Watch the DVD Read the booklet Review the Medication List and Quit Smoking Resources (inside front cover) Complete the Activity Log (inside front cover) Send us your evaluation after your postoperative visit or 2 to 3 weeks after your operation (inside back cover)

THIS PROGRAM WILL HELP YOU UNDERSTAND: ●● Your lungs and the type of operation you may need ●● The tests and home preparation needed weeks before your operation ●● How your surgical team (including you) will work to ensure the best recovery while you are in the hospital and at home

www.facs.org/patient education • YOUR LUNG OPERATION • EDUCATION FOR A BETTER RECOVERY 2 Your Lungs

Who Needs a Lung Operation? The main reason for having an operation on your lung is to remove a lung nodule or tumor. Other reasons include: ●● An abnormal X ray ●● Treatment of infection or scarring around the lung ●● Removal of sections of the lung that are diseased

Understanding Your Respiratory System Knowing how your lungs work is helpful in understanding your operation.

Trachea

YOUR LUNGS When you take a breath, air and oxygen Right Lung Left Lung pass from your mouth and nose through your trachea (windpipe) and right and left bronchus and into your lungs. Your lungs carry the oxygen through small tubes called bronchioles, and then to the alveoli. The alveoli are where the oxygen meets with the bloodstream. Oxygen is provided to the blood, and carbon dioxide is released back into the Mediastinum Heart (area between lungs) alveoli. As you breathe out, the carbon dioxide gas exits through your lungs and then out through your mouth. Trachea LUNG LOBES Lymph Nodes The lungs are divided into lobes. There are 3 lobes on your right side Right Upper Lobe and 2 lobes on your left side. Left Upper Lobe LYMPH NODES NEAR Left Bronchus Right Bronchus THE LUNGS Bronchioles The lungs also have a large supply of lymph nodes. The lymph Right Middle Lobe nodes are small, round masses Left Lower Lobe of tissue that filter the blood and Right Lower Lobe trap cancer cells and bacteria.

AMERICAN COLLEGE OF SURGEONS • DIVISION OF EDUCATION • PARTNERS IN YOUR SURGICAL CARE© Lung Cancer 3

Understanding Lung Cancer Staging If you are having this operation to remove a lung tumor, you will need to know a little more about the staging of lung cancer.

LUNG CANCER CELLS Lung cancer starts in the cells lining your lungs. Cancer cells grow faster and look abnormal in comparison with your healthy cells. The cancer cells continue to grow and eventually can be seen as a tumor on imaging tests. The cancer cells can spread (metastasize) to other parts of the lung and body. The stage of your cancer is determined by the size of the tumor and if there is spread to other areas. These areas include nearby lymph nodes and the mediastinum (area between the lungs).

YOUR CANCER REPORT On your cancer report, you Lymph nodes may also see the letters TNM. Stage I Stage III These are the letters used for cancer staging. They mean: T: Tumor size N: Nearby lymph nodes M: Metastasized or spread to other organs of the body

CANCER STAGE: NON– SMALL-CELL LUNG CANCER Stage I. The tumor is in Stage III. The tumor size is more the lung only and has not than 7 cm. It has spread to the The stages for non–small-cell spread to the lymph nodes. lymph nodes outside of the lung. lung cancer range from I, where It is 3 cm or less in size. For Stage IIIA, the cancer remains on there are some abnormal cells the same side as the original tumor. lining the airway, to stage IV, where the tumors have spread For Stage IIIB, the tumor has to other organs of the body. Stage II spread to lymph nodes above the collarbones or to the opposite side of the chest. The tumor can also be growing into the space between the lungs, the heart or large blood vessels, the trachea, and the esophagus. For more information on Stage IV. The tumor has spread cancer staging, please visit to other parts of the body, such the CancerCare website as the liver, bones, or brain. at http://www.lungcancer. Stage II. The tumor has spread org/reading/staging.php. to lymph nodes within the same lung. The tumor size is between 3 to 7 cm and may be blocking airways.

www.facs.org/patient education • YOUR LUNG OPERATION • EDUCATION FOR A BETTER RECOVERY 4 Understanding Your Operation

Your Operation: Removing a Section of Your Lung There are different approaches that your surgeon can do to remove part of your lung. The approach is based on the location and extent of your disease, the surgeon’s level of expertise, and your overall health.

Wedge Resection: Segmentectomy: A small, pie-shaped section from a lung lobe is removed. Each lobe contains between 2 and 5 segments. A segmentectomy removes one or more segments but less than the entire lobe.

Lobectomy: Pneumonectomy: An entire lobe is removed. The rest of the An entire lung is removed. The sac that contained lung inflates to fill up the space. the lung (pleural space) fills with fluid.

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Your Operation: Surgical Approach

VIDEO-ASSISTED THORACIC THORACOTOMY OTHER SURGICAL SURGERY (VATS) A 3- to 8-inch incision is made on your PROCEDURES For a VATS procedure, 2 to 4 small chest. It can extend from under your On rare occasions, your surgeon may incisions are made on the chest. Each arm around to your back. Some muscle decide to go in through the middle incision is about 1 to 3 centimeters is cut, and the ribs are spread apart. of your chest (median sternotomy). in length. Surgical tools and a Occasionally a small portion of the rib This approach may be used to reach thoracoscope (tube with a video must be removed to allow access to both right and left lungs, as well as camera and light source) are placed the lung. Sometimes smaller incisions lymph nodes in the mediastinal area. in the incisions. The lung tissue is cut under or near the armpit can be used away and placed in a small bag and for this procedure. This procedure is then removed through an incision. called a mini-thoracotomy. The size Nonsurgical Approach and location of the incision depends For patients who cannot have on the part of the lung being removed. an operation due to other medical conditions, stereotactic radiation therapy or other removal techniques may be an option.

www.facs.org/patient education • YOUR LUNG OPERATION • EDUCATION FOR A BETTER RECOVERY 6 Preoperative Tests

Preparation for your lung operation is important and can take time. It involves many tests, procedures, and discussions with your surgeon about your care and possible enrollment in clinical trials. There are also things you need to start doing at home weeks before your operation.

MAGNETIC RESONANCE IMAGING (MRI) Tests and Procedures A MRI uses radio waves and a magnetic field to get These tests help identify your current pulmonary detailed images of body organs. A brain MRI is the (lung) function, the extent of your disease, most sensitive test to detect brain metastasis. and your overall state of health. Tests may include: ●● Complete history and physical ●● Blood test ●● Urinalysis ●● EKG ●● Scans (CT, MRI, PET) ●● Chest X ray ●● Pulmonary function test

Pulmonary Function Test (PFT) A PFT measures the amount of air that you can breathe in and how much oxygen gets into your bloodstream. You usually shouldn’t eat or smoke for 4 to 6 hours before the test. Also, let your doctor know if you are using any inhalers.

Scans

COMPUTERIZED TOMOGRAPHY (CT) SCAN A CT scan is a special X ray that takes detailed cross-sectional images of the chest.

POSITRON EMISSION TOMOGRAPHY (PET) SCAN A PET scan uses a small amount of tracer injected into a vein. The scan then measures the amount of tracer absorbed by certain organs or tissues. Often a combined CT/PET scan is used to estimate if the tumor has spread.

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MEDIASTINOSCOPY Types of Lung Biopsy Procedures A scope is inserted between the lungs in a small incision Your surgeon will determine if you need a biopsy made above the breastbone or alongside the breastbone. (tissue sample). Sometimes a biopsy is done during the Tissue and/or lymph nodes are removed through the scope. operation. After the biopsy, the tissue sample is viewed under a microscope and checked for cancer cells. Sedation medication to help you relax or sleep is given before many of these procedures. You will need someone available to drive you home if sedation is used.

BRONCHOSCOPY A scope (thin tube with a light source on the end) is placed through your mouth or nose and into your trachea and large airways. A small amount of tissue BIOPSY OBTAINED DURING THORACOSCOPY from the surface of the airways is removed. OR VIDEO-ASSISTED THORACIC SURGERY A small cut is made in the skin between 2 ribs. A scope is inserted through the ribs and directed to the tumor site. The tissue is removed. The biopsy may lead to removal of a section of lung tissue.

Clinical Trials You may be asked to participate in a research study or clinical trial. Participation in a clinical trial may allow you access to newer experimental treatments. The clinical trial may benefit IMAGE-GUIDED FINE NEEDLE BIOPSY you and gives you the chance to help other patients in the Lung tissue is removed with a thin needle placed future. Your participation in these trials is optional. Your choice through the chest wall. An ultrasound or CT scan is to participate will not affect the quality of care you receive. used to locate exactly where the needle should be Your surgeon will discuss this possibility with you, and if you inserted. After the biopsy, a chest X ray will be taken to decide to participate, you will meet with a research coordinator. make sure that there is no air leaking from the lung. The research coordinator will talk to you further about the study and obtain your written permission to participate.

ENDO-BRONCHIAL ULTRASOUND (EBUS) A scope with a small, narrow needle hidden inside the tip of the scope is used. When the node or biopsy site is seen by the scope, the needle is inserted, and a sample of tissue is removed.

www.facs.org/patient education • YOUR LUNG OPERATION • EDUCATION FOR A BETTER RECOVERY 8 Home Preparation

Preoperative Home Skills Preparation These are the things you can do to help get yourself ready for your operation.

Quit Smoking Smoking increases your risk of problems during and after your operation. Quitting 4 to 6 weeks before your operation and staying smoke-free 4 weeks after it can decrease your rate of wound complications by 50%. Quitting permanently can add years to your life.

RESOURCES TO HELP YOU QUIT Talk to your health care provider about the best option to help you with quitting, but know how truly important it is that you decide to quit before your operation. Your chance for a better recovery The National Alliance for Tobacco Cessation provides PREPARE FOR YOUR QUIT DAY the latest information on how to quit smoking with its As listed on the American Cancer Society website: program called “Become an EX.” Proven methods to teach smokers how to quit and stay quit are provided. ●● Pick the date and mark it on your calendar. http://www.becomeanex.org/ ●● Tell friends and family about your Quit Day. ●● Get rid of all the cigarettes and ashtrays in The American Lung Association has information and your home, car, and place of work. plans like its “Freedom from Smoking” program, an ● online program that takes you through modules and ● Stock up on oral substitutes (sugarless gum, carrot sticks, hard candy, cinnamon sticks, provides you with the tools you need to quit. coffee stirrers, straws, and/or toothpicks). http://www.lungusa.org/stop-smoking/ ●● Decide on a plan. Will you use nicotine replacement The American Cancer Society has helpful detailed information therapy (NRT) or other medicines? Will you attend and a hotline number on its website. Call the American Cancer a stop-smoking class? If so, sign up now. Society at 1-800-227-2345 or visit http://www.cancer.org/ ●● Practice saying, “No thank you, I don’t smoke.” Healthy/StayAwayfromTobacco/GuidetoQuittingSmoking/index. ●● Set up a support system, which could be a group program such as Nicotine Anonymous or a friend or family member who has successfully quit. Ask family and friends who still smoke not to smoke around you or leave cigarettes out where you can see them. Successful quitting is a matter of ●● If you are using bupropion or varenicline, take your dose planning and commitment, not luck. each day of the week leading up to your Quit Day. Decide now on your own plan. ●● Think back to your past attempts to quit. Try to figure out what worked and what did not work for you.

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YOUR QUIT DAY On your Quit Day: ●● Do not smoke. This means none at all—not even one puff! ●● Keep active. Try walking, exercising, or hobbies. ●● Drink lots of water and juices. ●● Begin using nicotine replacement if that is your choice. ●● Attend a stop-smoking class or follow your self-help plan. ●● Avoid situations where the urge to smoke is strong. ●● Avoid people who are smoking. ●● Reduce or avoid alcohol. ●● Think about how you can change your routine. Use a different route to go to work, drink tea instead of coffee, eat breakfast in a different place, or eat different foods.

DEALING WITH WITHDRAWAL Nicotine replacement and other medicines can help reduce many of the physical symptoms of withdrawal. Most smokers find that the bigger challenge is the mental part of quitting. If you have been smoking for any length of time, smoking has become linked with nearly everything you do—waking up in the morning, eating, and drinking coffee. It will take time to “un-link” smoking from these activities, which is why, even if you are using a nicotine replacement, you may still have strong urges to smoke.

“Quitting smoking is probably one of the most importing things that you can do to help with your recovery.”

Traves Crabtree, MD, FACS Thoracic Surgeon

www.facs.org/patient education • YOUR LUNG OPERATION • EDUCATION FOR A BETTER RECOVERY 10 Home Preparation

Medications Your medications may have to be adjusted before your operation. Some medication can affect your recovery and response to anesthesia. Write down all of the mediations you are taking. A blank medication list is provided if you need it. Make a list. Your list should include: ●● Any prescription medications ●● Over-the-counter (OTC) medications (such as aspirin or Tylenol) ●● Herbs, vitamins, and supplements ●● Tell your doctor if you smoke and how often you drink alcohol or use other recreational drugs. List of medications that affect blood clotting:* Check with your doctor about: ●● Antiplatelet Medication: Anagrelide ® ●● When to stop taking all vitamins, herbs, and diet (Agrylin ), aspirin (any brand, all doses), cilostazol ® ® supplements (sometimes 10 to 14 days before (Pletal ), clopidogrel (Plavix ), dipyradamole ® ® and up to 7 days after your test or operation). (Persantine ), dipyridamole/aspirin (Aggrenox ), enteric-coated aspirin (Ecotrin®), ticlopidine (Ticlid®) ●● How to take your other morning medication (usually ● with a sip of water) the day of your operation. ● Anticoagulant Medication: Anisindione (Miradon®), enoxaparin (Lovenox®) injection, ●● How to adjust your insulin the morning of your heparin injection, pentosan polysulfate operation since you will not be eating. The (Elmiron®), warfarin (Coumadin®) doctor who normally manages your insulin ● often develops the plan for your operation. ● Nonsteroidal Anti-Inflammatory Drugs: Dabigatran etexilate mesylate (Pradaxa), diclofenac ●● The need to adjust your medication that affects blood (Voltaren®, Cataflam®), diflunisal (Dolobid®), etodolac clotting. These drugs may be adjusted up to 7 days (Lodine®), fenoprofen (Nalfon®), flurbiprogen before your operation. Your doctor will let you know (Ansaid®), ibuprofen (Motrin®, Advil®, Nuprin®, Rufen®), when to restart taking these drugs. (See following list.) indomethacin (Indocin®), ketoprofen (Orudis®, Actron®), ketorlac (Toradol®), meclofenamate (Meclomen®), meloxican (Mobic®), nabumeton (Relafen®), naproxen (Naprosyn®, Naprelan®, Aleve®), oxaprozin (Daypro®), piroxicam (Feldene®), prasugrel (Effient), salsalate (Salflex®, Disalcid®), sulindac (Clinoril®), sulfinpyrazone tolmetin (Tolectin®), trilisate (salicylate combination) ●● Herbs/Vitamins: Ajoene birch bark, cayenne, Chinese black tree fungus, cumin, evening primrose oil, feverfew, garlic, ginger, ginkgo biloba, ginseng, grape- seed extract, milk thistle, Omega 3 fatty acids, onion extract, St. John’s wort, tumeric, vitamins C and E *The above list includes common medications but is not a complete list.

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Exercise Breathing Exercises: Incentive Spirometer Deep breathing and aerobic exercise (those activities that require the lungs and heart to work harder) before Your incentive spirometer measures how much air and immediately following your operation may improve can go into your lungs. It helps you to exercise your your recovery. Exercise helps strengthen your pulmonary respiratory muscles and to breathe deeply. muscles and expand the breathing capacity of your lungs. Several studies have shown patients breathe easier, improve their ability to do physical and social activities, and improve their overall quality of life if they do exercise before and after their operation. Once approved by your doctor, you can begin your daily exercise. Try to start at least 2 weeks before your operation. An activity log is located in the front of your booklet to record how often and for how long you do each activity. Always know that it is okay to stop whenever you feel tired.

How to Use Your Incentive Spirometer ●● Begin by sitting up straight. ●● Hold the incentive spirometer in an upright position. ●● Exhale (breathe out) normally. ●● Place the mouthpiece into your mouth and seal your lips tightly around it. ●● Inhale (breathe in) slowly and as deeply as you can through the mouthpiece. ●● Hold your breath for at least 3 seconds, if you are able. ●● Note the highest level the indicator reached. ●● Exhale normally. Repeat this procedure 5 to 10 times. When to Use Your Incentive Spirometer Before Your Operation: Two weeks before your operation, you can use your incentive spirometer 4 to 5 times daily. If you do not get an incentive spirometer until you are in the hospital, then you can still practice by breathing deeply and holding your breath. Deep breathing exercises can be as effective as incentive spirometry. After Your Operation: Use your incentive spirometer every hour while you are awake. Continue to use it 4 to 6 times per day while you are home.

www.facs.org/patient education • YOUR LUNG OPERATION • EDUCATION FOR A BETTER RECOVERY 12 Home Preparation

Range-of-Motion Exercises After your operation, you will have some stiffness, pain, and swelling in your upper body. Range-of-motion exercises may help to keep your muscles and joints from tightening and help you to breathe more deeply. After your operation, ask your doctor if you can begin to do these exercises. You will need to be careful not to overstretch the area of your operation or where the chest tube was located. Head and neck exercise: TIlt your head so that your neck bends forward and your chin touches your chest. Then, raise your head so that you look up to the ceiling. Next, bend your head from side to side with your ear going toward your shoulder. Arm and shoulder exercise: Sitting Aerobic Exercise: straight in a chair or standing, slowly lift Walking or Riding a Bike your arm from your lap straight up over your head to the ceiling. Next, raise your Before Your Operation: Walk or ride a stationary arm from your side to the ceiling. Keep bike for 30 minutes each day. At first you may have to rest the elbow straight and your palm frequently, and that’s okay. Use your activity log to record downward. Hold for 10 seconds. how often and how long you can exercise each day. Repeat 3 to 5 times with each arm. In the Hospital: You should walk at least 3 times a day. Walk up exercise: Stand by a After Your Operation: Continue walking or riding a bike wall. With your elbow straight, use your after you return home. Mall walking is an option if you live in fingers to “crawl” up the wall or door a cold climate. Think of this activity as doing physical therapy frame as far as possible. Hold for 10 for your lungs. Continue to record your exercise in your log. seconds. Repeat 3 times with each arm.

Food and Drink Safety Checks ●● You should not eat or drink starting at midnight ●● An identification bracelet with your name and hospital before the operation (this rule includes candy, gum, number will be placed on your wrist. Your ID should be and coffee). Usually you can take your morning pills checked by the health care team before they provide with a sip of water, but check with your doctor. If you any procedures or give you medication. If you have are a diabetic, your insulin should be adjusted. allergies, you will also get an allergy alert bracelet. ●● You will be asked to confirm the location of your lung procedure (right or left). A member of the Shower or Bath/Hygiene surgical team will mark the side with a marker. ●● Clean your chest area with nonscented, mild, antibacterial soap (such as Ivory or Dial) the night before. Repeat the morning of your operation. Do not shave the surgical site. ●● You can brush your teeth and rinse your mouth with an antibacterial or antiseptic mouthwash. Doing so can decrease the amount of bacteria in your mouth and may decrease your risk of developing pneumonia.

What to Bring ●● Insurance card and identification Waiting Area ●● Advance directive form ●● You will change into the hospital gown, and ●● Loose-fitting, comfortable clothes all of your belongings will be labeled and placed in a locker or given to your family. ●● Nonslip shoes or slippers ●● You will meet with your anesthesia provider. Any ●● Toiletries (toothbrush, toothpaste, hairbrush) health problems will be reviewed. Your postoperative pain management plan will be discussed. What to Leave Behind ●● An intravenous (IV) line will be started to give you fluid and medications. ●● Leave jewelry and valuables at home. ●● You will have to remove all dentures, glasses, contact lenses, makeup, hairpins, hairpieces, Family Updates piercings, nail polish, and artificial body parts. ●● You will be in the operating room area for up to 6 hours. Ask your surgeon about how long your procedure should last. ●● Your family will be called when your operation is over.

www.facs.org/patient education • YOUR LUNG OPERATION • EDUCATION FOR A BETTER RECOVERY 14 After Your Operation

Your surgical team will closely monitor your recovery. You will be hooked up to many wires and tubes, including IV lines, a chest tube, a foley/bladder catheter, and oxygen, heart, and breathing monitors. Here is what you can expect and what we are closely watching for:

Pain Management ORAL MEDICATION You may initially feel sleepy and not remember much about You will usually be switched to oral pain medication the day. As you wake up, you may have some pain and the next day after your operation. These medications burning near the incision site and along the rib cage on the may include opioids (examples are Tylenol 3, Norco, and side of the operation. Controlling your pain is a top priority Vicodin) and nonsteroidal anti-inflammatory medication of your surgical team. A scale of 1 to 10 is used to measure (examples are Ibuprophen, Ketolac, and Motrin). You pain. At a 0 you do not feel any pain. A 10 is the worst pain may also have some sore throat pain from the tube that you have ever felt. Do not wait for your pain to reach 10 was placed in your throat during anesthesia to help you before telling your doctor or nurse. Extreme pain puts stress breathe. Throat lozenges may help with this pain. on the body and may prevent you from fully moving your chest and expanding your lungs following your operation. OTHER EFFECTS OF PAIN MEDICATION Some pain medications may cause itching, or lowers blood PAIN INFUSION PUMPS pressure. Your team will monitor for these side effects. Your pain will be controlled through a pain infusion pump Pain medication causes constipation. Your surgical team or medication given directly through your IV. Examples will ask you about when you have a bowel movement. of pain infusion pumps include a patient-controlled They will also give you medication to soften your stool analgesia (PCA) pump, a patient-controlled epidural and assist you in having daily bowel movements. analgesia (PCEA) pump, and a local infusion pump. ●● A PCA pump delivers pain medication through your IV. ●● A PCEA pump is a small tube (epidural catheter) Confusion After Your Operation placed in your back. It distributes numbing After your operation, you may become confused. The medication around the nerves to your chest. confusion can range from mild memory loss or anxiety to ●● A local infusion pump delivers small fear, hallucinations, and on occasion combative behavior. amounts of medication through small Sometimes the behavior can be worse at night. The severe tubes directly near the wound site. behavior is termed postoperative psychosis. It is rare and is seen more often with older patients, patients who experience You should be the only person pressing the pain sleep deprivation, and patients who spend longer periods of medication button. Family members should be aware time in the intensive care unit (ICU). If these symptoms occur, that they are not to press the pain medication button your family and friends will work with the health care team to for you. All pain pumps have high dose limits to make provide you with a calm, familiar, and reassuring environment. sure that you do not get too much medication.

Heart and Blood Pressure Breathing and Monitoring Preventing Pneumonia You may have electrodes (small bandages hooked to wires) After your operation, you may receive oxygen though placed on your chest to monitor your heart rate and breathing small tubes placed in your nose. Your oxygen will rate. You may also have an IV in your wrist that monitors your be monitored by a sensor placed on your finger. In blood pressure. A fast heart rate (atrial fibrillation) may occur rare cases, you may be sent home with oxygen. following a lung operation. This issue is usually temporary Pneumonia is an infection in the lungs. Signs of pneumonia and is treated with medication. Let your surgical team know are fever and shortness of breath. If pneumonia develops, if you feel your heart racing or feel tightness in your chest. you will be placed on antibiotics and may need additional oxygen. A bronchoscopy to remove secretions that may be Fluid Drainage and Air Leaks blocking your airway is done on rare occasions. Smoking and having other diseases can increase the risk of pneumonia. from Your Surgical Site You will have a drain or chest tube placed around your lung at the surgical site. It will be hooked up to a drainage container. Your team will measure the amount of drainage coming Studies show that there are ways to help through the tube. Your chest tubes are removed before you decrease the risk of developing pneumonia in go home, except on rare occasions. The amount of drainage surgical patients. Some of these ways include: you have will determine when your tube can be removed. You may feel some shoulder pain on the side of the chest tube. ●● Stop smoking 2 months before your operation. You will also be monitored for an air leak. Air can leak ●● Keep your head elevated at least from the surgical site to the space surrounding your lungs 30 degrees while in bed. (pleural space). The chest tube will allow the air to escape into the tube. Most air leaks stop within 1 to 5 days after the ●● Brush your teeth 2 to 3 times daily and surgical procedure. In rare cases, a patient may go home rinse with an antibacterial mouthwash. with a chest tube or require an additional operation. A chest ●● Get up and walk 3 times a day. X ray will be done to make sure that your lungs are fully ●● Do lung expansion exercises each expanded and air is not building up inside your chest cavity. hour while you are awake. • Take 5 to 10 deep breaths each hour and hold each breath for 3 to 5 seconds. • Use an incentive spirometer 5 to 10 times each hour. ●● Use a flutter valve, a device that helps you to cough and clear the mucus from your airways. You blow into it 4 to 5 times each hour to clear secretions. This is used mainly for patients with excess secretions and/or ineffective cough. Chest Tube

www.facs.org/patient education • YOUR LUNG OPERATION • EDUCATION FOR A BETTER RECOVERY 16 After Your Operation

Take Notes Preventing Blood Clots You will probably think of questions when the surgeon Blood clots can occur because of lying still and not is not present. Keep a notebook at the bedside to write moving during and after the surgical procedure. You down questions as they come to you. When the surgical will have special support stockings placed on your legs team comes by on rounds, you will be ready with your right before your operation. Sequential compression list of questions and you won’t miss a single one! stockings (stockings that fill with air and squeeze your legs) may also be applied. Getting up and walking early and as often as possible (3 to 4 times a day) also helps Bleeding decrease the risk of blood clots. Medications such as The amount of fluid you lose through your chest tubes heparin, fragmin, or lovenox may be given to prevent and incision site will be monitored. A blood transfusion clots. Heparin is given by injection into the abdomen and is rarely needed. Your blood counts will be monitored. may cause black and blue spots to appear on the belly. Do not be alarmed if bruising occurs, as it is common. Urinary Catheter and Urinary Retention Hoarseness or Vocal Cord Dysfunction A urinary catheter (tube) will drain urine from your bladder. Once you wake up, the tube will be removed. After the tube The vocal cords are 2 elastic bands of muscle located is removed, let your surgical team know when you go to right above the trachea. Swelling or pressure on the the bathroom and urinate. If you have trouble, you may be cord can cause changes in voice quality, hoarseness, given medication to help with normal urination. Problems and difficulty swallowing. These problems are urinating are more common in older men and when an usually treated initially with voice therapy. epidural catheter was used to control pain. The urinary catheter may also have to be placed back in for a short time. Preventing Infection Antibiotics will be given through your IV line right before your operation to prevent an infection. Redness and swelling at the incision site with fever can mean that there is a wound infection. You may need additional antibiotics.

How Long Will You Be Fatigue in the Hospital? It is normal to feel tired when you get home. You may require more sleep than you did before the operation. The typical length of a hospital stay after a lung operation is 2 to 5 days. Your stay may be longer or shorter depending on the complexity of the surgical procedure, your age, and Lifting Restrictions your overall health status. Let’s go through what you need to know as you recover and get ready for discharge. Do not lift anything heavier than 10 pounds (a gallon of milk is 9 pounds) for 1 to 3 months after your operation. Your doctor will provide you with more information Thinking Clearly about returning to heavy lifting after your operation. General anesthesia and your pain medication may cause you to feel sleepy and not think clearly. Do not drive, drink alcohol, Pain Management and or make any big decisions while on opioid pain medication. Chest Discomfort When you first get home, you may have more pain in the Nutrition evening. This is usually due to all of the activities you perform ●● Take a multivitamin. throughout the day. You might see that you can manage ●● Eat a balanced diet with food that is high in with one pain medication pill every 4 to 6 hours during the proteins. Proteins are necessary for recovery. day, but you need 2 at night. You will gradually decrease • Some examples of foods rich in protein include meats, the amount of pain opioid medication you need. You may beans, fish, eggs, nuts, milk, and milk products. need a nonsteroidal (such as Ibuprofen) for several weeks. • If you are having trouble eating a balanced Some patients feel stiffness in the chest. This problem can diet, you can use nutrition supplements such as be helped by taking a warm shower or by using a heating Ensure, Boost, or Carnation Instant Breakfast. pad. Place a towel between the heating pad and your chest. Some patients have breast or skin sensitivity and discomfort Activity for a longer period of time. They tell us that the side of the operation feels different than the other side. This feeling ●● You should be up and walking 3 to 4 times a day. Continue to increase the length of time that you can last for several months. Women say that wearing walk. Even if you can’t walk far, just getting up every a sports bra or supportive bra that has a larger chest hour and walking around your house is helpful. measurement (not cup size) is helpful. Place a small, clean gauze pad over the scar if your bra rubs the incision. ●● Use your incentive spirometer every 1 to 2 hours. Your activity log allows you to write down and keep track of your spirometer usage. Frequent Coughing ●● Continue doing the stretching exercises that you learned before your operation. Some patients have a frequent cough. You may find taking over-the-counter cough medicines to be helpful. ●● Do not drive while taking prescription pain You may cough up small amounts of dark blood the first medication, or until advised by your surgeon. few days after the operation, but this problem will begin to decrease over the next several weeks. The dark blood will change to mucus with just some blood streaks, and eventually to mucus with brown dried blood specks.

www.facs.org/patient education • YOUR LUNG OPERATION • EDUCATION FOR A BETTER RECOVERY 18 Your Recovery and Discharge

●● If you have skin glue, leave it in place. It will eventually fall off. ●● Your scar will heal in about 4 to 6 weeks and will become softer and continue to fade over the next year. ●● Avoid wearing tight or rough clothing, which may rub your incisions and make it harder for them to heal. ●● Slight tingling or numbness at the site is normal and can last for weeks. Wound Care Bowel Movement/Constipation You may have stitches or Dermabond glue on the site where your chest tube was removed. Pain medications can cause constipation. Regular Usually you go home with dressings or a small bowel movements should resume 2 to 3 days after adhesive bandage over your chest tube site. your operation. Drinking 8 to 10 glasses of fluid per day and eating a high-fiber diet can help. It is not unusual for the sites to have some drainage. ●● High-fiber foods include beans, bran cereals, whole- To change your dressing: grain breads, peas, dried fruits, raspberries, blackberries, ●● Start by washing your hands. strawberries, sweet corn, broccoli, baked potatoes ●● Remove the old dressing. with skin, plums, pears, apples, greens, and nuts. ● ●● Look at the wound for any redness, swelling, and ● If needed, you can also use over-the- drainage. The wound should not have a strong odor. counter fiber medications or laxatives. On the first days, the drainage will be pink in color and then will gradually turn to a clear/yellow. Returning to Work/School ●● Clean the skin around the site with soap and water. Many factors affect your ability to return to work or school, ●● Let the skin dry. including the type of job you have, how much lifting is ●● Apply a new gauze dressing attached with a small required, and the extent of your operation. Your surgeon piece of tape or a new adhesive bandage. will work with you to determine a safe time for your return. Here are a few other things that you should know about your wound site: Intimacy ●● You can take a shower the day after You can have sex when you feel ready and your wound your chest tube is removed. site has healed (usually 1 to 2 weeks postoperatively). ●● Do not soak in a bathtub until your stitches or Steri-strips are removed. ●● A small amount of drainage from the incision Cancer Survivorship Plan is normal. If you are changing the dressing If your operation was needed for lung cancer, ask your more than 3 times per day, or if it is soaked doctor about a cancer survivorship plan. You can also with blood or fluid, call your surgeon. refer to the survivorship plan in the front pocket. ●● If you have Steri-strips in place, they will fall off in 7 to 10 days. If they are still present after 10 days, you may remove them in the shower. ●● If you have a stitch at your chest tube site, your doctor will remove it at your first postoperative visit.

Partners in Your Surgical Care

Call your surgeon if you have: ●● Pain that gets worse or will not go away with pain medication ●● Constipation for 4 days ●● Worsening pain or swelling in your ankle or leg ●● Continuous nausea or vomiting ●● Urinary tract infection (pain when urinating or foul-smelling urine) ●● A new skin rash ●● Signs of infection ●● Wound swelling, redness, drainage that soaks your dressings, or foul-smelling drainage ●● A fever higher than 101 degrees Fahrenheit ●● Signs of pneumonia • Coughing, fever, fatigue, nausea, vomiting, rapid breathing or shortness of breath, chills, or chest pain. ●● If you run low on pain medication

Call 911 or go to your local emergency room if you have: ●● Sudden or sharp chest pain ●● Shortness of breath and feeling like your heart is racing ●● Continuously coughing up bright red blood ●● Sudden numbness or weakness in arms or legs ●● A sudden, severe headache SURGICAL ●● Fainting spells PATIENT ●● Severe abdominal pain EDUCATION

www.facs.org/patient education • YOUR LUNG OPERATION • EDUCATION FOR A BETTER RECOVERY www.facs.org/patient education

Thoracic Surgery Patient American College of Surgeons Staff Education Task Force Ajit K. Sachdeva, MD, FACS, FRCSC Director, Division of Education Traves Crabtree, MD, FACS Assistant Professor of Surgery Kathleen Heneghan, RN, MSN, PN-C Washington University Assistant Director, Division of Education, Surgical Patient Education St. Louis, MO Amanda Bruggeman Malcolm DeCamp, MD, FACS Coordinator, Division of Education Surgical Patient Education Program Fowler McCormick Professor of Surgery Patrice Gabler Blair, MPH Northwestern University Feinberg Associate Director, Division of Education School of Medicine Chief, Division of Thoracic Surgery Northwestern University Medical Center Resources and Collaborative Associations Chicago IL American College of Surgeons Surgical Patient Education Anne Marie Herlehy, DNP, RN, CNOR Program • www.surgicalpatienteducation.org Administrative Director, Perioperative American Association for Thoracic Surgery • www.aats.org and Cardiovascular Service The Society of Thoracic Surgeons • www.sts.org/patients Alexian Brothers Medical Center Association of PeriOperative Registered Nurses • www.aorn.org/ Elk Grove, IL Commission on Cancer • www.facs.org/cancer/ Daniel Miller, MD, FACS American Cancer Society • www.cancer.org/Cancer/index Professor of General Thoracic Surgery National Cancer Institute • www.cancer.gov/ Emory University National Comprehensive Cancer Network • www.nccn.org Atlanta, GA Filming locations: Northwestern Memorial Hospital, Northwestern University—Feinberg School of Medicine, Ara Vaporciyan, MD, FACS Brigham and Women’s Hospital, Washington University Medical Center, and Emory University Clinic Assistant Professor, Thoracic Surgery University of Texas, MD Anderson Cancer Center Houston, TX DISCLAIMER The information contained in the patient education section of the American College of Surgeons Stephen Yang, MD, FACS (ACS) website does not constitute medical advice. This information is published as a communications The Arthur B. and Patricia B. Modell vehicle: to inform and to educate the public about specific surgical procedures. It is not intended Professor and Chief of Thoracic Surgery to take the place of a discussion with a qualified surgeon who is familiar with your situation. It is important to remember that each individual is different, and the reasons and outcomes of any Johns Hopkins Medical Institutions operation depend upon the patient’s specific diagnosis, disease state, or other medical condition. Baltimore, MD The American College of Surgeons is a scientific and educational organization that is dedicated to the ethical and competent practice of surgery; it was founded to raise the standards of surgical practice and to improve the quality of care for the surgical patient. The ACS has endeavored to present information for prospective Patient Education surgical patients based on current scientific information; there is no warranty on the timeliness, accuracy, or usefulness of this content. Under no circumstances will the ACS be liable for direct, indirect, incidental, special Committee or punitive, or consequential damages that result in any way from your use of this electronic resource. The American College of Surgeons does not endorse any product or equipment Ajit Sachdeva, MD, FACS, FRCSC (Co-Chair) that may be used for the purposes of this educational project. H. Randolph Bailey, MD, FACS (Co-Chair) © American College of Surgeons, 2011 James Elsey, MD, FACS David V. Feliciano, MD, FACS Frederick L. Greene, MD, FACS Ted A. James, MD, FACS Marshall Z. Schwartz, MD, FACS Patricia Lynne Turner, MD, FACS

Questions? Please contact the Division of Education Surgical Patient Education Program office at [email protected] or 312-202-5263.

The Surgical Patient Education Program, “Your Lung Operation,” developed by the American College of Surgeons Division of Education, is made possible in part by the generous support of an educational grant from Ethicon Endo-Surgery.